On Thursday CPTPA Chief Fire Warden Howard Weeks signed an agreement with OSHA that reduced the fine to $10,500 and revised the citation. Originally OSHA accused CPTPA of not furnishing a place of employment that was free of “recognized hazards that were causing or likely to cause death or serious physical harm to employees”. OSHA said eight of the 10 Standard Firefighting Orders and 11 of the 18 Watch Out Situations were present and not mitigated in the citation issued to the CPTPA and the Notice issued to the USFS.

Below is an excerpt from an article at Firehouse.com that originally appeared in the Lewiston Tribune:

Idaho Department of Lands spokeswoman Emily Callihan said the original citation would have made it impossible for firefighters to do their jobs.

[…]

Callihan said the 10 and 18 are guidelines and not regulations, and the hazards they cover are present on nearly every fire. But, she said, the OSHA citation, as originally written, would have required firefighters to leave any fire where any of the 10 orders could not be followed or any of the 18 situations were present.

“What OSHA eventually recognized, is by removing firefighters from fires where any of those situations are present would result in not being able to respond with initial attack and keep fires small,” she said. “So it would have resulted in having fires get big and present more of a danger to firefighters and the public in the long run.”

The Wildfire Lessons Learned Center has released a video documenting the extraction of an injured firefighter from the 2011 Las Conchas Fire in northern New Mexico. Kenny Lovell of the Craig Interagency Hotshots is interviewed in the video and tells his story of being seriously injured, treated, and transported after being hit by a rolling rock. He suffered a broken pelvis, a broken fibula, and a large hematoma.

The title of the video, ROCK! Firefighter Extraction Success Story, describes the incident as a success. It was, in the sense that the Hotshot crew had access to equipment which was transported to the accident scene to treat and package the victim, there were several EMTs on the crew, the Hotshots had drilled for similar incidents, a helicopter with short haul capability was available, and 5 months later Mr. Lovell returned to work on the Hotshot crew. All that is great and the Hotshots and the helitack crew deserve praise for accomplishing what they did with the resources that were available..

Having said that, it is still troubling that 2 hours and 15 minutes elapsed before Mr. Lovell departed the accident scene in a helicopter, and 30 minutes later he arrived at a hospital. On the Deer Park fire in 2010 a firefighter with a broken femur was on the ground for 4 hours and 23 minutes before he was transported in a helicopter. And firefighter Andrew Palmer, who bled to death from a broken femur suffered on a fire in 2008, spent 2 hours and 51 minutes at the accident scene before he was extracted via hoist on a Coast Guard helicopter.

Agencies who place firefighters in remote areas should realize they have the ethical responsibility to supply the training, equipment, and aviation resources to at least begin transporting by air a seriously injured firefighter within an hour. I am surprised that OSHA has not cited the federal agencies for this. Of course getting injured firefighters to an appropriate hospital within the Golden Hour would be ideal, but depending on the distance involved that could be difficult. A helicopter with short haul capability can be helpful, but it is not the quickest or most efficient method for extracting an injured person. It involves several steps, especially, like in this case, when the helicopter responds to the scene without being fully configured for short haul.

Several agencies have helicopters with hoists which can quickly extract and then transport injured personnel from remote locations, including CAL FIRE, Los Angeles County Fire Department, and the Coast Guard. If the other federal and state agencies decided to take that step, it would not have to be a trial program with one helicopter like the U.S. Forest Service night flying helicopter effort this year, because other agencies have been using hoists (and night vision goggles) for decades,

“The organization is ethically and morally obligated to put an EMS program in place that is supported by the organization, and given the standardized training and equipment to make the program succeed.”

The above is from the 2010 facilitated learning analysis for the Deer Park Fire extraction, quoting a Senior Firefighter/Paramedic on the Sawtooth Helitack Crew.

The U.S. Forest Service has released their Serious Accident Investigation Report on the fatality of Ann Veseth, which occurred on the Steep Corner Fire 56 miles northeast of Orofino, Idaho August 12, 2012. The fire was on private property and was being managed by the Clearwater‐Potlatch Timber Protective Association (CPTPA). Ms. Veseth, in her second season working as a firefighter for the USFS, was killed when she was struck by a falling 150-foot tall fire-weakened green cedar tree. The tree fell on its own and was 13 inches in diameter where it struck her.

Ann Veseth. Photo from the report.

The report is unusual in at least two respects. It is written in the present tense, such as this:

Lee, the ENGB, works behind the E‐31 crew using a hoselay pumping water from the creek to secure fireline and watching for hazard trees.

In addition, there is a very nicely written one-page biography of the 20-year old firefighter which includes two photos.

The cause of this accident was that a green cedar tree, weakened by fire, fell and struck a firefighter in the head. It fell with a force far greater than the design limits of any hardhat could withstand. This tragedy resulted from the chance alignment of certain conditions: an emergency response to control a wildland fire, which required the presence of firefighters in an area where fire‐weakened trees could fall on their own with little or no warning. The SAI team concluded that the convergence of these events – in a very specific way and with very specific timing – resulted in a fatal accident. Slight differences in any number of factors could have led to drastically different results.

Firefighters faced the same choice on this fire as they do on almost every fire: engage the fire and expose firefighters to a certain set of risks in order to control the fire, or don’t engage the fire and don’t control it, knowing that such a decision often poses a wider range of risks to firefighters and the public. Firefighters made the same basic risk decision on the Steep Corner Fire as they do routinely on most fires: to engage the fire and attempt to control it, knowing that firefighters would be exposed to hazards during suppression efforts.

On the day of the accident, after the implementation of safety mitigation measures, the firefighting professionals involved in the Steep Corner Fire reasoned the risks of engaging and suppressing the fire to be acceptable. After considerable review of the incident, including the leadership, qualifications, interagency cooperation, fuels, weather, incident management organization, and local policies, the SAI Team concluded that the judgments and decisions of the firefighters involved in the Steep Corner Fire were appropriate. Firefighters all performed within the leaders’ intent and scope of duty, as defined by their respective organizations. The team did not find any reckless actions or violations of policy or protocol.

On August 11, the day before the fatal accident, two Forest Service resources decided to limit their acceptance of risk on the Steep Corner Fire. Both the IHC and the E‐31 crew identified necessary safety mitigations. The IHC chose not to engage. The E‐31 crew disengaged and indicated they would not return to the fire until mitigation measures were implemented.

C‐PTPA took these events seriously and subsequently addressed the recommended mitigation measures. Personnel became the “adapters” that allowed C‐PTPA and the Forest Service, two organizations with very different natural resource management mandates, to functiontogether. Mitigation measures included ordering more firefighting resources, adding line overhead and a radio repeater, and using contract fallers to fell hazard trees ahead of those digging fireline. The morning of August 12, the E‐31 crew decided to re‐engage when it became clear C‐PTPA was addressing their safety concerns. The IHC was already reassigned to anotherfire and did not return. In general, firefighters expressed their impressions that Saturday was a bad day but Sunday (before the accident) was much better, in terms of organization of the fire and mitigation of the hazards.”

(end of excerpt)

****

The 38-page report only has two recommendations. One is to introduce the LCES (Lookouts, Communications, Escape Routes, Safety Zones) concept into the National Wildfire Coordinating Group’s curriculum for use in disciplines other than fire management. The other is: “Occupational Safety and Health Office should develop a methodology for effectively teaching non‐fire workers the concepts related to hazard tree identification, scouting an area, and determining escape routes and safety zones for overhead hazards”.

An opinion

Several things about the incident and the report are troubling, but one item in the report stood out (emphasis added):

This tragedy resulted from the chance alignment of certain conditions: an emergency response to control a wildland fire, which required the presence of firefighters in an area where fire‐weakened trees could fall on their own with little or no warning.

Perhaps it is just an unfortunate choice of words chosen by the primary author which somehow was missed by the large number of people who probably reviewed the report before it was released. Giving them the benefit of the doubt, maybe they didn’t really mean to imply that firefighters are REQUIRED to perform an action on a fire simply because the fire is uncontrolled, even “where fire‐weakened trees could fall on their own with little or no warning”.

Someone might say that trees could fall during suppression action on most timber fires. Right. However on this fire, the large number of falling trees was identified the previous day, when a Hotshot crew refused to be assigned to the fire because of falling trees and many other unmitigated hazards, saying in a SAFENET report filed three days later that they “had huge concerns about the number of snags burning”. An engine crew left the fire for similar reasons that afternoon, but returned the next day after being assured that the hazards had been mitigated.

Firefighters are not REQUIRED to perform a task on a fire if there are known extraordinary hazards that cannot mitigated. We are talking about trees, grass, brush, or houses…. that will all grow back. Firefighters can’t.

The Citation for the CPTPA and the Notice for the USFS were both dated February 7, 2013.

The CPTPA citation was for the following:

Serious violation: For not providing a safe working environment; 8 of the 10 Standard Firefighting Orders were violated, and they did not mitigate 11 of the 18 Watch Out Situations. Proposed penalty: $4,900.

Thomas Marovich died on July 21, 2009 when he fell while performing routine helicopter rappelling proficiency training while assigned to the Backbone fire near Willow Creek, California. On October 2, 2009 the Occupational Safety and Health Administration (OSHA) issued “serious” and “willful” violation notices to the U. S. Forest Service for the incident.

The USFS has just released their Preliminary Aircraft Accident Investigation Report which was completed on October 19, 2009, and a Safety Action Plan dated February 1, 2010. The report is 63 pages long, but I will mention a few of the key points. [UPDATE 9-13-2011; the Lessons Learned Center removed the two reports from their site at the direction of the U. S. Forest Service, who said they were not intended to be released to the public. They replaced the two reports with the National Transportation Safety Board narrative.]

A proficiency rappel is required every 14 days to maintain technical competency. Marovich was in his first season rappelling and was about to make his 11th rappel.

Before the rappelling training, Marovich noticed that the Kong clip on his Tri-link was broken. The Kong Clip is used to center the “J” hook at the forward corner of the Tri-link. It is a nice piece of equipment to have, but is not essential. Kong clips are prone to breaking and are not popular. He sought assistance from a spotter trainee who replaced the Kong clip with an “O” ring, which was an authorized substitution. If I interpreted the report correctly, the “O” ring was installed incorrectly.

Here are some photos from the report showing for illustration purposes examples of a correct and then an incorrect installation of an “O” ring on a Tri-link.

“J” hook, Tri-link, and an “O” Ring, correctly installed. USFS photo.“J” hook, Tri-link, and an “O” Ring, incorrectly installed. USFS photo.Three different equipment rigging set ups. The top set up is rigged correctly using a Kong clip. The middle set up is rigged correctly using an O-ring. The bottom set up is rigged improperly using an O-ring. USFS photo.

Before the rappelling attempt, four people looked at or inspected Marovich’s rappelling gear: the spotter trainee who installed the “O” ring, Marovich, and in the helicopter a spotter, and another helitack crewperson who did a “buddy check”.

This photo was taken seconds before Marovich fell, unarrested. He is on the left side.

Marovich fell, unarrested, shortly after stepping out onto the helicopter skid. He was pronounced deceased about 30 minutes later.

The Human Factors section of the report, beginning on page 33, is particularly interesting. Written by Jim Saveland and Ivan Pupulidy, it discusses, along with other issues, the concept of not seeing elements in our visual field, or “blindness”.

To say that safety and health are no longer goals of the National Wildfire Coordinating Group (NWCG) seemed rather surprising, so I went to the link, which leads to an organization chart showing the Committees of the NWCG.

A portion of the chart is shown here on the right. As you can see, the organization is changing. The “Safety and Health Working Team” is becoming the “Risk Management” committee, and the “Incident Operations Standards Working Team” is merging with the “Training Working Team” to become the “Operations and Workforce Development” committee.

To say that “safety and health is no longer a goal” of the NWCG is misleading at best. And yes, the term “safety” in the organization chart has been replaced with “risk management”. But that does not mean that “safety and health is no longer a goal”.

Here are some definitions of the term “risk management”.

Risk Management is the identification, assessment, and prioritization of risks followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/or impact of unfortunate events. en.wikipedia.org/wiki/Risk_management

The process of determining the maximum acceptable level of overall risk to and from a proposed activity, then using risk assessment techniques to determine the initial level of risk and, if this is excessive, developing a strategy to ameliorate appropriate individual risks until the overall level of risk is reduced to an acceptable level. en.wiktionary.org/wiki/risk_management

Risk management is the active process of identifying, assessing, communicating and managing the risks facing an organization to ensure that an organization meets its objectives. www.lesrisk.com/glossary.htm

The technique or profession of assessing, minimizing, and preventing accidental loss to a business, as through the use of insurance, safety measures, etc. Origin: 1960–65. Dictionary.com

I exchanged some email messages with Michelle Ryerson, the fire safety program manager for the Bureau of Land Management, the current chair of the Safety and Health Working Team, and interim chair for the Risk Management Committee. I asked about the reason for the changes and she said the name change better reflects their approach to safe and effective fireline operations. The reorganization of the NWCG gave the groups an opportunity to change the names, encompassing a more comprehensive programmatic approach.

“We are in the process of converting over”, she said, “but have not been officially chartered under the new title of ‘Risk Management Committee’ (mission will remain the same) — plan to have conversion happen early spring of 2010 and will make note of it on our website”.